Pediatricians important in evaluation, management of bipolar disorder

John Sargent, MD

Dr. Benjamin Shain and the Committee on Adolescence of the American Academy of Pediatrics present an article describing the collaborative pediatric/child mental health system treatment of adolescents with bipolar disorder. The article includes descriptions of the various types of bipolar mood disorders and clearly articulates the diagnostic confusion resulting in narrow, intermediate and broad phenotypes of bipolar disorders. The authors include keys to diagnosis and specific questions the pediatrician can ask to suggest the possibility of a bipolar disorder in a teenager.

They highlight that the role of the pediatrician is not to make the diagnosis but rather to develop a suspicion and obtain a consultation and develop a treatment plan with a child and adolescent psychiatrist. The authors also include a cogent description of the treatment options and the appropriate use of psychopharmacology for the patients, including, at times, the need for more than one medication.

The role of psychosocial treatments is discussed through five illustrative cases included at the close of the article that demonstrate the variation of symptoms in these patients and the possible roles for pediatricians in managing these patients. The authors do not directly address the more controversial topic of bipolar disorder in preadolescents, although they refer to it briefly.

In May 2013, the American Psychiatric Association will publish a new diagnostic manual, the DSM-V, which will most likely include a new diagnosis for children and adolescents to cover those children with episodic rages without mood fluctuations to be named Severe Emotion Dysregulation Syndrome. The authors allude to this in the article and reference studies that show that over time this condition has a different course than bipolar disorders. They note that it will change how we diagnose and treat children with rage spells. Since this has not yet been published, this new information could not be included.

I agree with the authors that early recognition by pediatricians and collaborative ongoing care by a pediatrician and mental health team using a chronic illness model promises better care for these teens and their families. I strongly support the adoption of this knowledge and practice in pediatric primary care and strongly encourage mental health professionals to work closely with pediatricians in the care of these challenging patients.